Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

lithium 300 mg Cap [VDMC]

Facility

$1.75

Service Code	HCPCS A9270
Hospital Charge Code	10401297
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of IA Commercial	$1.58
Rate for Payer: Aetna of IA Medical Rental Products	$1.58
Rate for Payer: Cash Price	$1.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.32
Rate for Payer: Medical Associates Commercial	$1.32
Rate for Payer: Midlands Choice Commercial	$1.23
Rate for Payer: United Healthcare Commercial	$1.58

Lithium Level DMCL

Facility

$63.00

Service Code	CPT 80178
Hospital Charge Code	8037727
Hospital Revenue Code	301
Min. Negotiated Rate	$28.35
Max. Negotiated Rate	$71.85
Rate for Payer: Aetna of IA Commercial	$56.70
Rate for Payer: Aetna of IA Medical Rental Products	$56.70
Rate for Payer: Aetna of IA Medicare	$35.91
Rate for Payer: Amerigroup Medicaid	$36.34
Rate for Payer: Amerigroup Medicare	$28.63
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.35
Rate for Payer: Iowa Total Care Managed Medicaid	$35.99
Rate for Payer: Medical Associates Commercial	$47.25
Rate for Payer: Medical Associates Managed Medicare	$28.35
Rate for Payer: Midlands Choice Commercial	$44.10
Rate for Payer: Molina Healthcare Managed Medicaid	$36.51
Rate for Payer: Partners Health Alliance Commercial	$32.60
Rate for Payer: United Healthcare Commercial	$56.70
Rate for Payer: United Healthcare Managed Medicare	$37.17
Rate for Payer: Wellmark IA HMO WHPI	$65.23
Rate for Payer: Wellmark IA PPO	$71.85

Lithium Level DMCL

Facility

$63.00

Service Code	CPT 80178
Hospital Charge Code	8037727
Hospital Revenue Code	301
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of IA Commercial	$56.70
Rate for Payer: Aetna of IA Medical Rental Products	$56.70
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.25
Rate for Payer: Medical Associates Commercial	$47.25
Rate for Payer: Midlands Choice Commercial	$44.10
Rate for Payer: United Healthcare Commercial	$56.70

LITHOTRIPSY CHARGE

Facility

$4,114.00

Hospital Charge Code	8069084
Hospital Revenue Code	360
Min. Negotiated Rate	$1,851.30
Max. Negotiated Rate	$3,702.60
Rate for Payer: Aetna of IA Commercial	$3,702.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,702.60
Rate for Payer: Aetna of IA Medicare	$2,344.98
Rate for Payer: Amerigroup Medicaid	$2,372.96
Rate for Payer: Amerigroup Medicare	$1,869.81
Rate for Payer: Cash Price	$3,291.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,085.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,851.30
Rate for Payer: Iowa Total Care Managed Medicaid	$2,349.92
Rate for Payer: Medical Associates Commercial	$3,085.50
Rate for Payer: Medical Associates Managed Medicare	$1,851.30
Rate for Payer: Midlands Choice Commercial	$2,879.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2,384.47
Rate for Payer: Partners Health Alliance Commercial	$2,129.00
Rate for Payer: United Healthcare Commercial	$3,702.60
Rate for Payer: United Healthcare Managed Medicare	$2,427.26

LITHOTRIPSY CHARGE

Facility

$4,114.00

Hospital Charge Code	8069084
Hospital Revenue Code	360
Min. Negotiated Rate	$2,879.80
Max. Negotiated Rate	$3,702.60
Rate for Payer: Aetna of IA Commercial	$3,702.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,702.60
Rate for Payer: Cash Price	$3,291.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,085.50
Rate for Payer: Medical Associates Commercial	$3,085.50
Rate for Payer: Midlands Choice Commercial	$2,879.80
Rate for Payer: United Healthcare Commercial	$3,702.60

LIVER PROFILE

Facility

$111.00

Service Code	CPT 80076
Hospital Charge Code	633744
Hospital Revenue Code	301
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: United Healthcare Commercial	$99.90

LIVER PROFILE

Facility

$111.00

Service Code	CPT 80076
Hospital Charge Code	633744
Hospital Revenue Code	301
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Aetna of IA Medicare	$63.27
Rate for Payer: Amerigroup Medicaid	$64.02
Rate for Payer: Amerigroup Medicare	$50.45
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.95
Rate for Payer: Iowa Total Care Managed Medicaid	$63.40
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Medical Associates Managed Medicare	$49.95
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: Molina Healthcare Managed Medicaid	$64.34
Rate for Payer: Partners Health Alliance Commercial	$57.44
Rate for Payer: United Healthcare Commercial	$99.90
Rate for Payer: United Healthcare Managed Medicare	$65.49
Rate for Payer: Wellmark IA HMO WHPI	$60.97
Rate for Payer: Wellmark IA PPO	$67.17

LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT

Facility

$181,707.92

Service Code	MSDRG 005
Min. Negotiated Rate	$179,074.39
Max. Negotiated Rate	$181,707.92
Rate for Payer: Amerigroup Medicaid	$180,830.02
Rate for Payer: Iowa Total Care Managed Medicaid	$179,074.39
Rate for Payer: Molina Healthcare Managed Medicaid	$181,707.92

LIVER TRANSPLANT WITHOUT MCC

Facility

$102,212.81

Service Code	MSDRG 006
Min. Negotiated Rate	$100,731.42
Max. Negotiated Rate	$102,212.81
Rate for Payer: Amerigroup Medicaid	$101,718.99
Rate for Payer: Iowa Total Care Managed Medicaid	$100,731.42
Rate for Payer: Molina Healthcare Managed Medicaid	$102,212.81

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC

Facility

$20,004.11

Service Code	MSDRG 496
Min. Negotiated Rate	$19,714.18
Max. Negotiated Rate	$20,004.11
Rate for Payer: Amerigroup Medicaid	$19,907.46
Rate for Payer: Iowa Total Care Managed Medicaid	$19,714.18
Rate for Payer: Molina Healthcare Managed Medicaid	$20,004.11

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC

Facility

$40,930.39

Service Code	MSDRG 495
Min. Negotiated Rate	$40,337.18
Max. Negotiated Rate	$40,930.39
Rate for Payer: Amerigroup Medicaid	$40,732.64
Rate for Payer: Iowa Total Care Managed Medicaid	$40,337.18
Rate for Payer: Molina Healthcare Managed Medicaid	$40,930.39

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC

Facility

$12,837.26

Service Code	MSDRG 497
Min. Negotiated Rate	$12,651.21
Max. Negotiated Rate	$12,837.26
Rate for Payer: Amerigroup Medicaid	$12,775.24
Rate for Payer: Iowa Total Care Managed Medicaid	$12,651.21
Rate for Payer: Molina Healthcare Managed Medicaid	$12,837.26

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC

Facility

$29,106.51

Service Code	MSDRG 498
Min. Negotiated Rate	$28,684.66
Max. Negotiated Rate	$29,106.51
Rate for Payer: Amerigroup Medicaid	$28,965.88
Rate for Payer: Iowa Total Care Managed Medicaid	$28,684.66
Rate for Payer: Molina Healthcare Managed Medicaid	$29,106.51

LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC

Facility

$12,159.43

Service Code	MSDRG 499
Min. Negotiated Rate	$11,983.20
Max. Negotiated Rate	$12,159.43
Rate for Payer: Amerigroup Medicaid	$12,100.68
Rate for Payer: Iowa Total Care Managed Medicaid	$11,983.20
Rate for Payer: Molina Healthcare Managed Medicaid	$12,159.43

LOCKING COMPR BROAD 10 HOLE / L 191MM

Facility

$251.00

Service Code	HCPCS C1713
Hospital Charge Code	8046758
Hospital Revenue Code	278
Min. Negotiated Rate	$112.95
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna of IA Commercial	$225.90
Rate for Payer: Aetna of IA Medical Rental Products	$225.90
Rate for Payer: Aetna of IA Medicare	$143.07
Rate for Payer: Amerigroup Medicaid	$144.78
Rate for Payer: Amerigroup Medicare	$114.08
Rate for Payer: Cash Price	$200.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$112.95
Rate for Payer: Iowa Total Care Managed Medicaid	$143.37
Rate for Payer: Medical Associates Commercial	$188.25
Rate for Payer: Medical Associates Managed Medicare	$112.95
Rate for Payer: Midlands Choice Commercial	$175.70
Rate for Payer: Molina Healthcare Managed Medicaid	$145.48
Rate for Payer: Partners Health Alliance Commercial	$129.89
Rate for Payer: United Healthcare Commercial	$225.90
Rate for Payer: United Healthcare Managed Medicare	$148.09

LOCKING COMPR BROAD 10 HOLE / L 191MM

Facility

$251.00

Service Code	HCPCS C1713
Hospital Charge Code	8046758
Hospital Revenue Code	278
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna of IA Commercial	$225.90
Rate for Payer: Aetna of IA Medical Rental Products	$225.90
Rate for Payer: Cash Price	$200.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.25
Rate for Payer: Medical Associates Commercial	$188.25
Rate for Payer: Midlands Choice Commercial	$175.70
Rate for Payer: United Healthcare Commercial	$225.90

LOCKING COMPR BROAD 11 HOLE / L 209MM

Facility

$279.00

Service Code	HCPCS C1713
Hospital Charge Code	8046759
Hospital Revenue Code	278
Min. Negotiated Rate	$125.55
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$160.93
Rate for Payer: Amerigroup Medicare	$126.81
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.55
Rate for Payer: Iowa Total Care Managed Medicaid	$159.36
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$125.55
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$161.71
Rate for Payer: Partners Health Alliance Commercial	$144.38
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61

LOCKING COMPR BROAD 11 HOLE / L 209MM

Facility

$279.00

Service Code	HCPCS C1713
Hospital Charge Code	8046759
Hospital Revenue Code	278
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

LOCKING COMPR BROAD 12 HOLE / L 227MM

Facility

$279.00

Service Code	HCPCS C1713
Hospital Charge Code	8046760
Hospital Revenue Code	278
Min. Negotiated Rate	$125.55
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$160.93
Rate for Payer: Amerigroup Medicare	$126.81
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.55
Rate for Payer: Iowa Total Care Managed Medicaid	$159.36
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$125.55
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$161.71
Rate for Payer: Partners Health Alliance Commercial	$144.38
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61

LOCKING COMPR BROAD 12 HOLE / L 227MM

Facility

$279.00

Service Code	HCPCS C1713
Hospital Charge Code	8046760
Hospital Revenue Code	278
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

LOCKING COMPR BROAD 13 HOLE / L 245MM

Facility

$279.00

Service Code	HCPCS C1713
Hospital Charge Code	8046761
Hospital Revenue Code	278
Min. Negotiated Rate	$125.55
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$160.93
Rate for Payer: Amerigroup Medicare	$126.81
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.55
Rate for Payer: Iowa Total Care Managed Medicaid	$159.36
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$125.55
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$161.71
Rate for Payer: Partners Health Alliance Commercial	$144.38
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61

LOCKING COMPR BROAD 13 HOLE / L 245MM

Facility

$279.00

Service Code	HCPCS C1713
Hospital Charge Code	8046761
Hospital Revenue Code	278
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

LOCKING COMPR BROAD 14 HOLE / L 263MM

Facility

$279.00

Service Code	HCPCS C1713
Hospital Charge Code	8046762
Hospital Revenue Code	278
Min. Negotiated Rate	$125.55
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$160.93
Rate for Payer: Amerigroup Medicare	$126.81
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.55
Rate for Payer: Iowa Total Care Managed Medicaid	$159.36
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$125.55
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$161.71
Rate for Payer: Partners Health Alliance Commercial	$144.38
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61

LOCKING COMPR BROAD 14 HOLE / L 263MM

Facility

$279.00

Service Code	HCPCS C1713
Hospital Charge Code	8046762
Hospital Revenue Code	278
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

LOCKING COMPR BROAD 6 HOLE / L 119MM

Facility

$224.00

Service Code	HCPCS C1713
Hospital Charge Code	8046754
Hospital Revenue Code	278
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of IA Commercial	$201.60
Rate for Payer: Aetna of IA Medical Rental Products	$201.60
Rate for Payer: Aetna of IA Medicare	$127.68
Rate for Payer: Amerigroup Medicaid	$129.20
Rate for Payer: Amerigroup Medicare	$101.81
Rate for Payer: Cash Price	$179.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$168.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$100.80
Rate for Payer: Iowa Total Care Managed Medicaid	$127.95
Rate for Payer: Medical Associates Commercial	$168.00
Rate for Payer: Medical Associates Managed Medicare	$100.80
Rate for Payer: Midlands Choice Commercial	$156.80
Rate for Payer: Molina Healthcare Managed Medicaid	$129.83
Rate for Payer: Partners Health Alliance Commercial	$115.92
Rate for Payer: United Healthcare Commercial	$201.60
Rate for Payer: United Healthcare Managed Medicare	$132.16

Know your out-of-pocket cost for care.

All Charges